Who Wins the Race for Patients-the ER or the Urgent Care Center?

Tracy Hume, a freelance writer who lives in Greeley, Colo., and a reader of Thinking About Health columns, recently sent along this provocative question. "Do ER-affiliated urgent care providers ever try to escalate patients to the ER when it is not medically necessary?" she asked. "Why? How should a consumer respond?"

She explained that over the July 4 weekend, her teenage son had complained of nausea, headache, abdominal pain and was throwing up. Alarmed, she took him to an urgent care center, which was in her insurance plan's provider network.

A clerk at the clinic inquired about his symptoms and immediately said since he was having abdominal pains he needed a CT scan, and the urgent care center did not have the capability to do that test. He would have to go to the emergency room across the street part of the same hospital system.

Hume thought twice. The copay at the urgent care center was $75; at the ER it was $250. Plus, she told me, no one at the center had bothered to examine her son to see if he even needed a CT scan, a procedure that researchers say is overused in the country's emergency rooms. Dr. Rita Redberg, a prominent cardiologist at the University of California, San Francisco Medical Center, has pointed out, "CTs, once rare, are now routine. One in l0 Americans undergo a CT scan every year, and many of them get more than one." They are becoming common in emergency rooms where patients are getting scans at rates five times higher than in the mid 1990s.

While some CT scans undoubtedly save lives, if you get one and don't need it, you're exposing yourself to needless radiation. Redberg says the use of medical imaging with high doses of radiation, particularly CT scans, has increased "more than six-fold between the 1980s and 2006." What's behind the growing use? Fears of malpractice suits and patient demand for them "just to be sure," as I reported in my last column, are partly to blame but so is the presence of more of these machines along with the financial pressures on the hospitals to use as revenue generators.

And that reason circles back to Hume. Was the hospital system sending patients to a place of higher-priced care to pad its bottom line? Hume did say that there are two "large aggressively competitive healthcare systems competing for business" in Greeley, a city of almost 100,000 people, and "each built fancy, fully-equipped new ERs on the affluent side of town within a two-mile radius of each other."

We know that relationship marketing is common in banking and other services, why not hospitals? If your marketing strategy is to get more patients through the doors of the ER, where the cost of care is highest, why not? In a piece for Kaiser Health News in 2011, reporter Phil Galewitz wrote hospitals are using "aggressive marketing of ERs to increase admissions and profits." To achieve that goal, they had started advertising ER wait times on billboards and smart phones to lure anxious moms with sick kids to the ER with the shortest wait.

Hume's experience suggests that some patients at urgent care centers might be a source of revenue for the ER as well. And, yes, directing patients to emergency rooms runs counter to one of health reform's goals---to keep people out of the ER. By giving people health insurance, they now had a way to pay for visits to a doctor's office. But what's a patient to do in the face of all this marketing?

Hume had a solution: she took her son to another urgent care clinic not affiliated with either hospital system. The clinic accepted her $75 insurance copay, a physician's assistant examined her son, questioned him about his symptoms, felt his abdomen, diagnosed gastroenteritis and prescribed an anti-nausea medication. He was better in a couple days. No CT scan, no unnecessary radiation, no expensive copay.

Urgent care clinics are not created equal. Hume asked what's a consumer to do. It seems she answered her own question.

The Rural Health News Service is funded by a grant from The Commonwealth Fund and distributed through the Nebraska Press Association Foundation, the Colorado Press Association, the South Dakota Newspaper Association and the Hoosier (IN) State Press Association